Prosthetics and Orthotics International, 1986,
Prosthetic use in adult upper limb amputees: a comparison
of the body powered and electrically powered prostheses
S. G. M I L L S T E I N , H. H E G E R and G. A. H U N T E R *
Amputee Clinic,
Abstract
Three hundred and fourteen adult upper limb
amputees were reviewed retrospectively at the
Ontario Workers' Compensation Board. A
questionnaire was used to evaluate the use of
body and electrically powered prostheses.
Follow-up ranged from 1 to 49 years with a mean
of 15 years. Results indicated that complete or
useful acceptance of an electrically powered
prosthesis was reported by 69 of 83 amputees
( 8 3 % ) ; 199 of 291 amputees ( 6 8 % ) used the
cable operated hook, 57 of 291 ( 2 0 % ) used the
cable operated hand and 40 of 83 ( 4 8 % ) used the
cosmetic prosthesis. The majority of amputees
used more than one prosthesis for their
functional needs and should be fitted with more
than one type of prosthesis. Acceptance of an
upper limb prosthesis by 8 9 % (196/220) of
below-elbow, 7 6 % (56/74) of above-elbow and
6 0 % (12/20) of high level amputees indicates
that for most upper limb amputees, their
prostheses are well used and essential to their
personal and employment activities.
Introduction
The Amputee Clinic at the Workers'
Compensation Board, Downsview
Rehabilitation Centre provides Ontario workers
who have sustained an amputation in a work
related accident with medical, prosthetic,
psychosocial and vocational services. The
multidisciplinary treatment team consists of a
physician co-ordinator, nurse, prosthetist,
physiotherapist, occupational therapist,
remedial gymnast, social worker, research
associate, vocational rehabilitation counsellor,
secretary and medical director of the Clinic, who
is an orthopaedic surgeon.
All correspondence to be addressed to Ms. S. G.
Millstein, Research Physiotherapist, Amputee Clinic,
Ontario Workers' Compensation Board, Downsview
Rehabilitation Centre, 115 Torbarrie Road,
Downsview, Ontario, M 3 L 1 G B , Canada.
10, 27-34
Ontario Workers' Compensation Board
The impact on a person due to the sudden loss
of a hand or arm cannot be overstated.
Prosthetic fitting and training is crucial to
successful rehabilitation and reintegration of the
amputee into society.
The loss of fine, co-ordinated movements of
the hand, tactile sensation, proprioceptive
feedback, and aesthetic appearance can only be
compensated for to a limited extent by the three
types of prostheses that are at present available.
These are a body powered and cable operated
prosthesis with a split hook or hand as a terminal
device; an electrically powered prosthesis
controlled by muscle sensors (myoelectric) or by
microswitches; and a cosmetic replacement with
a passive hand.
The standard practice at this Amputee Clinic
is initially to fit and train each below and
above-elbow amputee with a cable operated
prosthesis supplied with one or more hooks and
a hand. Following the evaluation of a request for
a myoelectric or cosmetic prosthesis, these
prostheses may also be provided. Shoulder
disarticulation and forequarter amputees are
fitted from the onset of prosthetic training with
electrically powered prostheses. The supply of
more than one prosthesis has evolved from the
recognition that different kinds of prostheses are
frequently used in combination by the amputee
to meet a variety of functional needs.
Although several research projects, including
those at the Downsview Rehabilitation Centre
have been undertaken to assess the value of the
electrically powered prosthesis, (Herberts et al,
1980; Northmore-Ball et al, 1980; Millstein et al,
1982; Heger et al, 1985), there are very few
detailed reports on the acceptance and use of the
body powered prosthesis. (Fletcher, 1970; Vitali
et al, 1978; Stein and Walley, 1983; van
Lunteren et al, 1983; Chan et al, 1984).
* Sunnybrook Medical Centre, Toronto, Ontario.
27
28 5. G. Millstein, H. Heger and G. A. Hunter *
The purpose of this present review was to
assess the use of the various types of body
powered and electrically powered prostheses for
different levels of upper extremity amputations
in adults in order to determine their function and
acceptance. Advantages and disadvantages of
each prosthesis were examined to determine the
factors that influence the amputee's choice of an
upper extremity prosthesis over a long period of
time.
Patients and methods
The population surveyed included 314
patients, who had sustained a single upper limb
amputation in a work related accident and had
been treated by the Workers' Compensation
Board Amputee Clinic. There were 45 wrist
disarticulations, 175 below-elbow amputations,
3 elbow disarticulations, 71 above-elbow
amputations, 15 shoulder disarticulations and 5
forequarter amputations.
The amputee's age at amputation ranged from
14 to 68 years with a mean of 34 years. The
average age of the patients at review was 49
years, the oldest being 82 and the youngest 15.
There were 302 men and 12 women. The period
between accident and follow-up ranged from 1
to 49 years with a mean of 15 years. The
dominant side was amputated in 54 per cent of
the population. Nine per cent had a revision of
their amputation, of these 4 8 % were revised to a
higher level and 5 2 % at the same level.
Evaluation included the completion of a
standard questionnaire and a review of patients'
records. The questionnaire examined the use of
the various types of prostheses in activities of
daily living, work and recreation. The questions
were concerned with the amount of time a
prosthesis was actually worn, its use and
reliability and the problems the amputee
encountered. For those amputees who
possessed more than one type of prosthesis, a
comparison was made in regard to the time the
prostheses were worn and the activities for
which they were used. The results of the
questionnaire were coded and analyzed using
the Statistical Analysis System.
Results
Ninety-six per cent of the amputees reported
having a prosthesis at the time of review.
Eighty-five per cent had a cable operated
prosthesis with hook(s), 5 5 % a cable operated
hand, 1 0 % a cosmetic prosthesis and 2 5 % an
electrically powered prosthesis.
At the below-elbow level, 9 5 % (209/220) of
the amputees had originally been fitted with a
cable operated hook and 6 9 % (145/209) of those
amputees fitted were using this prosthesis. At
the above-elbow level, 8 9 % (66/74) had been
fitted and 7 3 % (48/66) were using it, and at the
higher levels, 8 0 % (16/20) had been fitted and
3 8 % (6/16) were using it.
Although the same number of amputees at
each level had been fitted with a cable operated
hand, there were considerably fewer amputees
making use of this prosthesis. Only 2 1 % (44/209)
at the below-elbow level, 1 8 % (12/66) at the
above-elbow level and 6% (1/16) at the higher
levels reported using the cable operated hand.
Considerably fewer amputees had been fitted
with a cosmetic prosthesis, but some had
converted their cable operated hand into a
cosmetic prosthesis with a nonactive hand by
disconnecting the cable.
With respect to the cosmetic prosthesis, at the
below-elbow level 2 6 % (58/220) had been fitted
and 5 9 % (34/58) were using it, at the above-
elbow level 2 7 % (20/74) had been fitted and 2 0 %
(4/20) were using it and at the higher levels 2 5 %
(5/20) had been fitted and 4 0 % (2/5) were using
it.
One third (72/220) of below-elbow amputees
had been fitted with an electrically powered
prosthesis and 8 2 % (59/72) of those fitted
reported using it, 9% (7/74) of above-elbow
amputees had been fitted and 8 6 % (6/7) were
using it and 2 0 % (4/20) of high level amputees
were fitted and all (4/4) were using it.
The number of hours of use on an average
work day and weekend day indicated that these
prostheses were well used. The cable operated
hook was used for an average of 8 hours each
work day and 7 hours on a weekend day. The
electrically powered prosthesis was worn for an
average of 8 hours each day throughout the
week. The cable operated hand was used for an
average of 5 hours each day and the passive
cosmetic hand was worn an average of 4 hours
each day.
The number of amputees using the various
types of prostheses for an average of less than 4
hours per day, 4 - 8 hours per day and more than
8 hours per day is shown in Figure 1. There is
very little difference in usage by time between
the cable operated hook and electrically
 Prosthetic use in adult upper limb amputees 29

Fig. 1. Prosthetic use on average week day and weekend day.

powered prosthesis or between the cable
operated hand and cosmetic prosthesis. During
the week, (as indicated by the broken black
line), the cable operated hook and electrically
powered prosthesis were used the most often for
over 8 hours and the cable operated hand and
cosmetic prosthesis were used for the least
number of hours.
For the cable operated hook as many as 7 3 %
of amputees reported they used it more than 8
hours on an average work day (Fig 1.). For the
electrically powered prosthesis, 6 4 % used it
more than 8 hours during the week, 5 5 % for the
cable operated hand and 5 6 % for the cosmetic
hand. On the weekend, there was a change in the
pattern of use of all types of prosthesis. More
amputees were using their prostheses for shorter
periods of time (less than 8 hours) rather than for
longer periods of time (more than 8 hours) as
was the case during the week. On the weekend
5 8 % of amputees reported using the cable
operated hook more than 8 hours, 5 9 % of
amputees used their electrically powered
prosthesis, 4 6 % used the cable operated hand
and 4 2 % used the cosmetic prosthesis.
Those upper limb amputees who reported
rarely or never using their prosthesis, identified
pain with limited function as the principal
reasons. Other reasons included harness and
stump problems. The percentage of nonusers
was 1 1 % (25/220) at the below-elbow level, 2 4 %
(18/74) at the above-elbow level and 4 0 % (8/20)
at higher levels (Table 1).
Prosthetic activities of use
Amputees were asked to indicate for what
activities they used a prosthesis and which type
of prosthesis they used for that particular

Table 1. Prosthetic use of body powered and electrically powered prostheses.

30 S. G. Millstein, H. Heger and G. A. Hunter *
Fig. 2. Prosthetic use-functional activities.
activity. Figure 2 reflects a wide range of
responses indicating a very varied preference by
amputees.
At work
Sixty-six per cent of upper limb amputees
reported using their prostheses at work. The
choice of using a cable operated hook/hand,
cosmetic prosthesis or electrically powered
prosthesis depended on the requirements of the
amputee. Amputees who used the electrically
powered prostheses primarily had jobs that
involved office work, supervisory work or
contact with the general public. They were able
to utilize the electrically powered prosthesis in
their work tasks because of their light activities
in a relatively clean environment. Those
amputees who used a cable operated prosthesis
had jobs that required heavy lifting or their work
environment was unsuitable. It was generally
dirty, materials to be handled were greasy or
sharp and the danger of damaging the glove or
prosthesis was high. For these jobs, the cable
operated hook was more suitable because of its
ruggedness and durability.
Exposure to extremes of weather can be a
problem with the electrically powered
prosthesis. Very cold weather will interfere with
the function of the battery, and outdoor work in
winter time can be uncomfortable because the
stump may become very cold. Hot humid
weather conditions or working strenuously can
cause excessive sweating, leading to the loss of
myoelectric control.
Activities of daily living
The extent to which body powered or
electrically powered prostheses were used for
activities of daily living was quite diverse. Below
and above-elbow amputees found both types
useful for eating, personal care and dressing.
However, most high level amputees found their
prosthesis less useful and used it only
occasionally for activities of daily living.
Recreational use
Both body powered and electrically powered
prostheses were used for a variety of sports and
recreational activities. The most popular
activities for which prostheses were beneficial
included golf, fishing, gardening and minor
home and car repairs.
Some amputees played baseball, broomball,
or pool, while some were active in camping,
canoeing, hunting and curling or hockey. The
cable operated hook was preferred for heavier
and more vigorous activities and some used the
cable operated hand for specific sports.
Social use
The amputees liked the cosmesis of the
electrically powered prosthesis and wore it for
 Prosthetic use in adult upper limb amputees
many social events. It was found to be
considerably more acceptable in the social
sphere than the cable operated hook. It was
quite often not noticed or if noticed, it elicited
amazement, interest and more positive
comments than the hook. The electrically
powered prosthesis was used most often for
eating, holding objects and occasionally driving
a car. High level amputees tended not to make
active use of it often in a social setting as they felt
the use would lead to greater attention directed
toward them. However, they appreciated the
availability of function when they desired it,
combined with increased comfort. A few
amputees did not mind wearing their cable
operated hook in a social setting. However,
many preferred using the cable operated hand
and cosmetic prosthesis rather than the hook if
they did not possess an electrically powered
prosthesis.
In an attempt to ascertain which prosthesis
satisfied our amputees' needs the most,
calculations were made to determine how many
amputees used one prosthesis exclusively and
how many used a combination of two or more
prostheses (Table 1). Approximately 1/3 (102/
314) of amputees used the cable operated hook
exclusively and approximately 1/3 (100/314)
used a combination of more than one prosthesis.
Although only 9% (27/314) of amputees used
the electrically powered prosthesis exclusively,
the majority of amputees have been fitted with
cable operated hook/hands whereas
considerably fewer have been fitted with
Fig. 3. Acceptance of body powered and electrically powered prostheses.
31
electrically powered prostheses. Amputees
predominantly used the cable operated hook
and electrically powered prosthesis in
combination relative to their functional
requirements. Only 5% (16/314) and 6% (18/
314) respectively of amputees used the cable
operated hand and cosmetic prosthesis
exclusively.
Acceptance
For any prosthesis to be accepted and used by
the amputee, it must be comfortable, functional
and have a pleasing appearance. Other
contributing factors that influence acceptance,
are the quality of the stump, the level of the
amputation, manual dexterity and motivation of
the amputee.
Complete or useful acceptance of an upper
limb prosthesis was reported in 8 9 % (196/220) of
below-elbow amputees, 7 6 % (56/74) of above-
elbow amputees and 6 0 % (12/20) of high level
amputees. The majority of amputees used more
than one prosthesis for their functional needs at
work, home, recreation and social events.
Amputees indicated that the most preferred
prosthesis was the electrically powered
prosthesis. The cable operated hook was the
second most favoured followed by the cosmetic
and cable operated hand.
Figure 3 illustrates the acceptance and use of
the four types of prostheses. Since the majority
of amputees have more than one prosthesis,
there were multiple responses to this question.
For the cable operated hook the acceptance
32 S. G. Millstein, H. Heger and G. A. Hunter *
rate was 6 9 % (145/209) at the below-elbow
level, 7 3 % (47/64) at the above-elbow level and
3 8 % (6/16) at higher levels. The low acceptance
rate by high level amputees is due to the high
energy expenditure necessary to achieve limited
function with a cable operated prosthesis. A
wide range of acceptance rates for body powered
prostheses exists in the literature from 3 4 %
(73/213) at the below-elbow level and 2 8 %
(29/103) at the above-elbow level by Vitali et al,
(1978) to 9 0 % (18/20) by Chan (1984).
The cable operated hook is especially
advantageous for hobbies and jobs which
require manual skills because of the following
properties: it provides good sight of the grasped
object; it is not easily damaged; it is designed for
rugged conditions; it is easy to clean. An obvious
disadvantage of the cable operated hook is the
lack of cosmetic appeal. It is also difficult to
stabilize some objects with the split hook, due to
its shape and sometimes insufficient gripping
force. To overcome some of these shortcomings,
amputees may interchange their split hook with
other hooks or terminal devices that have been
designed for use in specific tasks or hobbies.
The cable operated hand has a very low
acceptance rate at 2 1 % (44/209), 1 8 % (12/66)
and 6% (1/16) for the various levels. Amputees
have found the hand difficult to operate,
awkward, and heavy. It is not durable and has a
weak grip. This prosthesis is occasionally used
for specific sports or work activities or as a
nonactive prosthesis for cosmesis.
The acceptance of the cosmetic passive
prosthesis covers a wide range from 5 9 % (34/58)
for below-elbow amputees to 2 0 % (4/20) for
above-elbow and 4 0 % (2/5) for high levels.
Amputees reported using this prosthesis
primarily for social events. It is gradually being
discarded in favour of the electrically powered
prosthesis which offers cosmesis combined with
function.
The high acceptance rate of 8 2 % (59/72) at the
below-elbow level, 8 6 % (6/7) at the above-
elbow level and 100% (4/4) for high level
amputations for the electrically powered
prosthesis is very positive (Fig 3 ) , and it appears
that amputees strongly favour this prosthesis,
especially high level amputees. However, as yet,
at this Centre only 3 3 % of below-elbow
amputees, 9% of above-elbow amputees and
2 0 % of high level amputees have been fitted with
the electrically powered prosthesis. A review at
this Centre that followed up all 164 amputees
fitted with electrically powered prostheses,
resulted in an 8 0 % (104/130) acceptance rate at
the below-elbow level, 6 9 % (11/16) at the
above-elbow level and 7 2 % (13/18) at the high
2
level. (Heger et al, 1985). A Chi test was done
and the difference between acceptance rates for
the three levels of amputation between the two
studies was not statistically significant. Our
acceptance rate at the below-elbow level
compares favourably with the acceptance rates
reported by Herberts (1980) and Stein and
Walley (1983), who reported 37% (14/38) and
60% (14/23) at the below-elbow level
respectively.
The advantages of electrically powered
prostheses are:
1. Increased comfort because of lack of
harness suspension for below-elbow
amputees and simpler harnesss for higher
level amputees.
2. Cosmetic acceptance by amputees and the
general population. Although for some
amputees, the lack of a large-sized
prosthetic hand in comparison to the
amputee's hand (largest available size is 8)
may lead to unsatisfactory cosmetic appeal.
3. Superior pinch force (15 to 251bs.)
compared with the cable operated hook (7
to 81bs.).
4. Control of the myoelectric prosthesis is
more natural and less strenuous;
movements of the hand and elbow units are
independent of the position of the body.
5. For high level amputees, whose physical
impairment is severe, the electrically
powered prosthesis is a viable alternative to
the cable operated prosthesis, because it
provides a greater range of function and
requires less energy expenditure.
6. Some sensory feedback has been reported
by some amputees between the stump and
prosthesis, the vibration of the motor and
controlling muscle contraction.
7. Short below-elbow stumps can be provided
with good function through skillful fitting of
the Muenster socket.
The disadvantages of electrically powered
prostheses at the present time are:
1. High cost factors in initial fitting
(approximately twice as expensive as cable
operated) and ongoing repairs (average of
two repairs per year for our amputees).
 Prosthetic use in adult upper limb amputees
2. Myoelectric service must be carried out in a
specialized Centre.
3. The electrically powered prosthesis is not as
durable as the cable operated prosthesis
because it has not been designed for heavy
work in regard to its suspension, wrist
connection, handframe and glove. Many
amputees were reluctant to' use the
electrically powered prosthesis for some
specific activities for fear of damaging the
glove or its components. The current
electric elbows have been criticized because
they are too noisy, have limited strength,
and move too slowly for functional
purposes.
4. The shape of the hand makes some precise
tasks more difficult.
5. The prosthesis requires more maintenance,
eg. recharging the battery regularly and
cleaning the glove.
6. The suspension of the Muenster socket and
resultant weight distribution may cause
discomfort and magnify the apparent weight
of the prosthesis for some amputees.
The acceptance of prosthetic devices by upper
limb amputees is a very complex process in
which several important factors interact.
Prosthetic fit and reliability are of special
importance, but psychological and
socioeconomic factors play important roles.
Another review at this Centre on employment
patterns of industrial amputees included the 314
upper limb amputees in this study. It was found
that 8 8 % of these upper limb amputees were
employed at the time of review (Millstein et al,
1985). Prosthetic use by upper limb amputees
was positively associated with return to work.
Our experience shows that good acceptance
figures for body powered and electrically
powered prostheses can be obtained if prosthetic
fitting and training is combined with the services
of a multidisciplinary team. Patients must be
followed up regularly and prosthetic fitting
changed according to the changing needs of
patients.
Conclusions
The findings of this review of 314 upper limb
amputees confirm that complete or useful
acceptance of an upper limb prosthesis was
reported in 8 9 % of below-elbow amputees, 7 6 %
of above-elbow amputees and 6 0 % of high level
amputees. Prostheses are well used and essential
33
to the amputees' personal and employment
activities. Most upper limb amputees should be
fitted with both a body powered and electrically
powered prosthesis to meet their various
functional requirements. The benefits of these
prostheses far outweigh their costs.
The cable operated hook is well accepted and
used by the majority of amputees for heavy work
and precision tasks at work and at home. It
provides good sight of the grasped object, is not
easily damaged and is easy to clean. The cable
operated hand and cosmetic prosthesis are used
by a small number of amputees primarily for
cosmesis at social occasions. In spite of the high
initial cost and continued maintenance and
repair, improvement in comfort, cosmesis and
function have led to good levels of acceptance of
the electrically powered prosthesis. For high
level amputees, it provides better function,
superior pinch force and requires less energy
expenditure than the body powered prosthesis.
The multidisciplinary team approach, at the
Amputee Clinic, patient follow-up and service
have contributed to the very positive results of
this review. These findings, combined with daily
interaction with patients at the Amputee Clinic,
suggest that upper limb amputees have the
motivation and the ability to overcome the loss
of a hand.
Acknowledgements
It is a pleasure to thank and acknowledge the
skill of the prosthetists Mr. William Burt of the
Ontario Workers' Compensation Board and Mr.
William Sauter of the Ontario Crippled
Children's Centre, who have fitted and serviced
these prostheses.
The authors would further like to thank Mr.
George Suranyi M. Sc. of the Policy Planning
Secretariat at the Ontario Workers'
Compensation Board for his assistance.
The financial support of the Ontario Workers'
Compensation Board which has allowed review
of these patients is much appreciated. Dr. R. I.
Mitchell, the Executive Director of Medical
Services warrants special recognition for his
support of the Amputee research.
REFERENCES
C H A N , K . M., L E E , S . Y . , L E U N G , K . K., L E U N G , P . C ,
( 1 9 8 3 ) . A medical-social study of upper limb
amputees in Hong Kong — a preliminary report.
Orthot. Prosthet. 37(4), 4 3 - 4 8 .
34 S. G. Millstein, H. Heger and G. A. Hunter *

LONDON, P. S., (1970). Upper limb amputations. Br. NORTHMORE-BALL, M . D . , HEGER, H., HUNTER, G ;
J. Hosp. Med. 4, 590-595. A. (1980). The below-elbow myoelectric prosthesis:
a comparison of the Otto Bock myoelectric
H E G E R , H . , M I L L S T E I N , S., H U N T E R , G . A . (1985). prosthesis with the hook and functional hand. J.
Electrically powered prostheses for the adult with Bone Joint Surg. 62B, 363-367.
an upper limb amputation, J. Bone Joint Surg. 67B,
278-281.
STEIN, R. B., WALLEY, M. (1983). Functional
H E R B E R T S , P., K O R N E R , L . , C A I N E , K . , W E N S B Y , L . comparison of upper extremity amputees using
(1980). Rehabilitation of unilateral below-elbow myoelectric and conventional prostheses. Arch.
amputees with myoelectric prostheses. Scand. J. Phys. Med. Rehabil. 64, 243-248.
Rehabil. Med. 12, 123-128.

M I L L S T E I N , S., B A I N , D . , H U N T E R , G. A. (1985). A VAN L U N T E R E N , A . , VAN L U N T E R E N - G E R R I T S E N , G .

review of employment patterns of industrial H . M . , STASSEN, H . G . , ZUITHOFF, M . J . ( 1 9 8 3 ) . A
amputees: factors influencing rehabilitation. field evaluation of arm prostheses for unilateral
Prosthet. Orthot. Int., 9, 69-78. amputees. Prosthet. Orthot. Int. 7, 1 4 1 - 1 5 1 .

M I L L S T E I N , S., H E G E R , H . , H U N T E R , G . A . (1982). A
review of the failures in use of the below-elbow VITALI, M., ROBINSON, K. P., ANDREWS, B G.,
myoelectric prosthesis. Orthot. Prosthet. 36(2), H A R R I S , E. E. (1978). Amputations and prostheses.
29-34. London: Bailliere Tindall, 10.